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Wednesday, April 4, 2012

Name 5 Tests or Treatments We Overuse in Geriatrics or Palliative Care

For the most part in geriatrics and palliative care we like to point the finger at other medical providers and say, "STOP." Stop giving so much chemotherapy. Stop giving so many medications. Stop scanning.

But now it's time to take a long hard look in the mirror.

Medical specialty organizations are being asked to come up with a list of 5 tests or treatments that are over-utilized or may actually be harmful. This effort, called the Choosing Wisely Initiative, is being spearheaded by the American Board of Internal Medicine (ABIM) Foundation. ABIM President and renowned geriatrician Christine Cassel was quoted in today's New York Times saying:

“In fact, rationing is not necessary if you just don’t do the things that don’t help.”

This same article notes that as much as 1/3 of health care costs are wasted on unnecessary hospitalizations, tests, and treatments.

So far 9 specialty boards have come up with their lists - the boards and there list are here - but Geriatrics and Palliative Medicine are not one of the 9. Are we really "holier than thou?" I don't think so.

I suspect we can come up with 5 tests or treatments for each specialty. It might be more fun to come up with lists for the cardiologists, oncologists, or surgeons, but that's not the point. Ask not what another specialty should not be doing, but what you can do less of yourself.

It's easier to come up with ideas if you don't think of them as a hard and fast rules (never do x), but as a list of things doctors and patients should question routinely doing in geriatrics or palliative care.

So to jump start things, here are two from each field:

Geriatrics
1. Screening for cancer in patients who are unlikely to benefit.
2. Insulin sliding scales

Palliative Care
1. Using more expensive analgesics without evidence of superiority to less expensive alternatives
2. Using oxygen instead of forced air

Let's figure this out together. Or someone from another specialty may come up with our list for us!

Thanks Alex for getting this conversation started. AGS will be working on our list over the summer and will be in the second wave of organizations (announcement slated for early fall). I believe AAHPM is on the same timeframe. We welcome everyone's thinking on this topic.

Thank you for calling attention to this initiative. AAHPM is now an official partner of the Choosing Wisely campaign and will be participating in the next round of recommendations (to be released in the fall). Keep an eye on www.aahpm.org for details about how to contribute to the Academy’s process of determining 5 tests and interventions that warrant closer examination by patients and physicians.

Use of Aricept and other drugs in this class in patients who are bed bound with advanced dementia. Ditto Namenda. Continuing cholesterol lowering medications and Plavix in patients with a 6 month life expectancy. Swallow evals-this has become a whole industry-total waste of time. Low specificity and sensitivity and patients refuse to take the thickened liquids and then get dehydrated. Screening for things not likely to result in improved quality of lie.

1. Stop Fosamax/antibone resorptive medications for patients with dementia or bed bound patients.2. Review reasons for PPI use or continued usage3. Lipid, EKG, HbA1c mandatory testing by pharmacists for patients on Antipsychotics in severely demented patients or those on hospice care.

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